Payer Enrollment and Credentialing Auditor

The Payer Enrollment and Credentialing Auditor’s responsibility will be to conduct daily audits of the Medicare applications for all PTANS/TINS prior to applications being submitted for both the Medicare 855I and Medicare 855B records. Additional auditing will be conducted in the Credentialing records to ensure compliance with NCQA standards as well as to ensure that all addresses are present in the group record.

Primary Job Duties:

• Under the direction of the Director, conducts daily audits of the Medicare applications prior to submission to ensure they are being submitted correctly and accurately under the appropriate PTAN, locality, and TIN.
• Conducts monthly audits of at least 10% of credentialing files and 25% of group records for purposes of data integrity and shares findings with leadership for any action that is needed.
• Tracks and trends errors in the system and provides monthly reports to leadership with results.
• Conducts monthly audits of TIN ORs to ensure that no billing row has exceeded the 90 day limit. Share findings with leaders to take action where appropriate.
• Attends regularly scheduled meetings (no less than biweekly) with leaders to share results and concerns based on audits.
• Reviews monthly rosters for any data errors/issues and shares those results with the leadership team for action.
• Makes recommendations for controls and process improvements to the leadership team.
• Follows guidelines in alignment with all health plan requirements as related to the provider certification and credentialing.
• Follows all CMS guidelines with regard to both individual and group enrollment identifying areas of opportunity and sharing that with the leadership team.
• Interacts with varied levels of management, physician office staff and physicians effectively to accomplish credentialing and various elements of implementation and launch
• Plans audits by understanding organization objectives, structure, policies, processes, internal controls, and external regulations. Identifies risk areas that support the policy scope and creates audit measures accordingly.
• Continuously assesses the Credentialing and Enrollment compliance with company guidelines and external regulations and makes effective recommendations for process improvements.
• Identifies gaps in current processes / procedures, completes an analysis and provides recommendations for policy / procedure revisions and process improvements.
• Due to the sensitive nature of quality audits, ensures that audit records and information are maintained in confidence within the Department and communicated only to affected Leadership.
• Coordinate and prepare reports for the leadership team.
• Record and track credentialing statistics.
• Other duties as assigned.

Requirements

• 5+ years experience in Medicare enrollment, managed care credentialing, billing and/or Medical Staff service setting
• Knowledge and experience using credentialing software such as Verity Credential Stream is a plus
• Demonstrated skills in problem solving and analysis and resolution
• Advanced Microsoft Excel skills
• Must be able to function independently, possess demonstrated flexibility in multiple project management
• Must comply with HIPAA rules and regulations
• Prefer knowledge of EFT, ERA, EDI enrollment and claims systems.

Interpersonal Skills & Attributes:

• An individual with the ability to communicate appropriately and effectively with practitioners, internal stakeholders, and providers; including sensitive and confidential information
• High level of attention to detail with exceptional organizational skills
• Exercise independent judgment in interpreting guidelines of applicable regulatory bodies.

The salary range for this role is $60,000.00-$68,000.00 in base pay and exclusive of any bonuses or benefits. This role is also eligible for an annual bonus targeted at 10%. The base pay offered will be determined based on relevant factors such as experience, education, and geographic location.